LONDON FOOT & ANKLE SURGERY
Mr Andy Roche MSc FRCS (Tr & Orth) Consultant Orthopaedic and Trauma Surgeon specialising
in Foot and Ankle Surgery and Reconstruction

Stress Fractures

What are stress fractures?

A stress fracture is fracture of a bone most commonly seen in the foot or lower leg that is generally caused by overuse of a limb. It is due to repetitive loading of a bone that is not able to normally maintain the repetitive frequent stresses applied to the leg.

How does a stress fracture normally occur?

Typical cases occur in athletes who change training habits or intensity. Running on unfamiliar hard surfaces can predispose to injury. Sudden increases or constant sessions in playing or training time can potentially cause injury.

Different factors may predispose athletes to this injury. These include subtle abnormal foot postures and movements on running or improper footwear and surfaces. Inappropriate diet can potentially affect the bones ability to respond to stress applied and finally hormone imbalances can reduce the bones mineralisation and thus its ability to withstand repetitive stresses. 

What are the anatomical areas most prone to development of a stress fracture?

The vast majority of stress fractures occur in the foot and lower leg. Most commonly seen in

  • The tibia or shin bone
  • The metatarsal bones in the foot
  • The fibula or lateral malleolus at the ankle
  • The tibia or medial malleolus at the ankle
  • The calcaneum or heel bone
  • The navicular bone in the foot
  • The talus bone in the foot
  • The sesamoid bones under the big toe 

What activities are more likely to develop stress fractures?

  • Track and field athletes
  • Dancers
  • Tennis
  • Gymnastics
  • Footballers
  • Long distance walking (including military personnel)

Why may women get more stress fractures than men? 

Female athletes who suffer from irregular menses (periods) are more likely to develop stress fractures due to the reduced or erratic oestrogen hormone production and the positive effect it has on bone metabolism and strength. There is a classic combination of disorders that can be found even in teenage girls who are keen athletes. This is a combination of disordered eating habits, ammenorhea (absent periods) and osteoporosis (low bone density). 

What are the symptoms?

Localised pain in the area of the suspected fracture. For example In the tibia or shin, pain radiates on the shin bone on impact, in the 5th metatarsal pain is located to the outer aspect of the foot, in calcaneum injuries pain is located under the heel. The pain eases on rest but recurs on activity resumption.

What should you do if you are concerned you may have a stress fracture?

Persistent pain in the absence of significant trauma should highlight the possibility of a stress fracture. Clinical assessment by an Orthopaedic foot and ankle surgeon is advised who has access to multimodal investigation and treatment facilities. Commonly statements made to the doctor are “I don’t remember hurting myself” or “I havent really changed my training schedule” or “I thought the ache was nothing to worry about”.

How are stress fractures accurately diagnosed?

This depends on duration of the symptoms because if the stress fracture is very fresh or recent then plain X-Rays may not show up anything, until around 3 weeks after the symptoms start. If an X-Ray shows the stress fracture, patients are often a little shocked when the surgeon says “It looks like that been there for quite a while!”. because it is not uncommon for the X-Ray to show a fracture that looks like it has been “trying to heal” for some time. A very sensitive test is an MRI scan which nowadays is usually performed to help diagnose some fractures.

How is a stress fracture normally treated?

The chronic nature of the symptoms, level of activity (professional/amateur), timing during the season and nature of the fracture (displaced or non-displaced, they are usually non-displaced) all dictate the treatment.

In general non-operative treatment is usually initiated. This involves COMPLETE REST FROM RUNNING or activity performed. You may be given a plaster cast or rigid boot and crutches. Repeated examinations and follow-up MRI scans can check healing. As symptoms resolve training can be gradually re-instituted. In the meantime aerobic activity can be maintained by exercise such as swimming, deep-water running and cycling.

Although not the rule, but specific injuries where surgery may be advocated early, especially in those athletes wishing to return to sports quickly include: 

  • Medial malleolus fractures
  • 5th metatarsal fractures

What are the usual outcomes?

Most heal uneventfully between 1 month and 3 months. If the fracture progresses or activity is instituted too early, prolonged rest is required. If pain continues newer treatments are showing promising results such as shockwave therapy that you can get. Failing all non-operative treatments may lead to operative stabilisation of the fracture with internal metalwork. Some athletes may choose to go straight to operative fixation if they felt non-operative therapy would be too prolonged but this can be discussed with your surgeon.

Prevention 

  • Be sensible in your training goals, do not push too hard too quick
  • Vary your training between impact training such as running with lower impact training such as cycling
  • Prepare well with good dietary intake
  • Make sure you are well equipped with correct shoes
  • If you experience pain or problems don’t push it. Rest and restart. If persists see an Orthopaedic foot and ankle surgeon 
  • Chelsea & Westminster Hospital NHS
  • The Lister Hospital, Chelsea
  • Fortius Clinic
  • Bupa Cromwell Road